A clinical documentation improvement is a communication tool that during clinical documentation improvement is used to communicate between a clinical documentation improvement professional and the provider.
What role does medical communication have in medical documentation?
The what, why and how of clinical care given to patients are communicated through documentation. These data give other medical professionals access to patient histories, enabling them to continue offering each patient the best care possible. Clinical Documentation Improvement (CDI) is the process of enhancing medical records to guarantee better patient outcomes, high-quality data, and precise compensation. In reaction to the introduction of DRGs (Diagnosis Related Groups) as a method of payment, hospitals started CDI programs.A patient's paper chart gets converted to digital form in an electronic health record (EHR). EHRs are patient-centered, real-time records that securely and promptly make information accessible to authorized users.
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